Abdominal complications of ventriculoperitoneal shunts. Case reports and review of the literature.

Ventriculoperitoneal (VP) shunting of cerebrospinal fluid (CSF) is the standard therapy for the management of hydrocephalus. Before the advent of silastic, early abdominal complications were frequent and finally led to the abandonment of this technique for management of hydrocephalus. With the use of silastic shunt tubing, VP shunts have once again gained favor as the procedure of choice. Although there are now considerably fewer complications from VP shunts, the presence of an intraperitoneal catheter can still initiate various complications. Abdominal complications of VP shunts are reported to be from 10-30 per cent, thus remaining clinically important for early recognition and treatment in patient management. An awareness of these complications is necessary in creating an index of suspicion for the primary physician whose patients harbor a VP shunt and present with abdominal symptoms. This report presents five cases of children with abdominal complications of VP shunts (four pseudocysts and one umbilical granuloma with spontaneous drainage of CSF). Additional abdominal complications of VP shunts are discussed, as well as diagnostic and therapeutic alternatives in order to improve and expedite accuracy in diagnosis and provide simplicity and efficiency in treatment.

Pneumocephalus secondary to tension pneumothorax associated with comminuted fracture of the thoracic spine.

We present an unusual case of pneumocephalus secondary to a tension pneumothorax associated with fracture of the thoracic spine. Air from a pneumothorax entered the thoracic intraspinal compartment and the intracranial cavity through a comminuted fracture of the spine. The pneumocephalus and the pneumothorax resolved after aspiration of the intrathoracic air via an intercostal catheter. Diagnosis, therapeutic modalities, and potential complications of a pneumocephalus and of a communication between the thoracic cavity and the spinal dural space are discussed.

Radiographic, clinical, and histopathologic evaluation with surgical treatment of Forestier's disease.

Diffuse idiopathic skeletal hyperostosis (Forestier's disease) is a common disorder found in the spinal region, but the notable finding in this case presentation is the associated dysphagia and dysphonia that occurred with it. Asymptomatic hypertrophic spurs of the anterior surface of the cervical vertebrae may occur in 20% to 30% of the population. Rarely, dysphagia and/or dysphonia may be caused by these cervical osteophytes pressing against the esophagus, trachea, or pharyngeal tissues. A recent case of spondylitic dysphagia exhibited striking radiographic and computerized tomographic (CT) findings. In this case, the anterior cervical exostosis was resected through the anterior cervical approach with excellent relief of dysphagia.

Complications associated with intra-arterial BCNU administered in combination with vincristine and procarbazine for the treatment of malignant brain tumors.

We have used intra-arterial (i.a.) 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) either alone or as part of adjuvant chemotherapy in patients with malignant brain tumors over a 3 year period (1979-1982). The i.a. BCNU technique was used 111 times to infuse 134 arteries in 37 patients. These patients, 28 cases with glial tumor and 9 cases with brain metastasis, received i.a. BCNU in combination with Vincristine and Procarbazine every 6 weeks. Complications encountered were transient and included: periorbital erythralgia or occipital-nuchal pain in 23 (62%), mild confusion and disorientation in 14 (38%), and ipsilateral conjunctival edema in 10 (27%). Reversible myelosuppression was not found. Our findings suggest that BCNU (100 mg/M2) may be given by i.a. infusion in combination chemotherapy without persistent severe untoward effects with a cumulative dose of 700 mg/M2.

Therapeutic benefits of combination chemotherapy with vincristine, BCNU, and procarbazine on recurrent cystic craniopharyngioma. A case report.

The authors report a case of recurrent cystic craniopharyngioma managed with chemotherapy. The patient refused adamantly the alternative therapy methods, such as surgery and radiotherapy, initially offered. Eight courses of chemotherapy with vincristine (2 mg/M2, i.v.) on day 1,1,3-bis(2-chloroethyl)-1-nitrosourea (100 mg/M2, i.v.) on day 2, and procarbazine (50 mg, b.i.d., p.o.) on days 3 to 21 were administered at 6 week intervals. The effectiveness of this treatment modality has been evaluated by the unequivocal neurological improvement and by the decreases in size of the cyst using serial computerized tomography. Toxocities were mild and chiefly hematological.

Autogeneic fat transplants in the epidural space in routine lumbar spine surgery.

This report presents our experience with the use of autogeneic fat patch grafts to protect the exposed dura mater during lumbar spine operations. A total of 44 consecutive surgical procedures was performed primarily for discogenic or spondylotic disease from 1979 to 1982. Prophylactic antibiotics were used in 21 (48%) cases. The autogeneic fat transplants were well accepted by all recipients during 10.4 (1 to 32) months of follow-up. Fat grafts, greater than 1 cm in thickness, were easily identified on subsequent computed tomographic (CT) scans. There were no postoperative wound infections. However, 1 patient developed a large subcutaneous sterile fluid accumulation at the fat donor site, which required surgical intervention. Our results, both short and long term, indicate that autogeneic fat transplants may be well tolerated in the lumbar spine area. The fat graft viability as demonstrated by CT scanning and histological examination supports the contention that autogeneic fat interposed between dura mater and overlying musculature may serve as a barrier limiting the growth of cicatrix into the spinal canal.

An unusual late complication of acrylic spinal fusion: case report.

The authors report an unusual complication after posterior cervical spine fusion utilizing methyl methacrylate and metallic pins. Eight months postoperatively, the patient noticed a subcutaneous foreign body in the right side of the neck. Radiographic and operative findings confirmed the clinical impression of migration of one of the metallic pins.

Internal metal plate fixation combined with anterior interbody fusion in cases of cervical spine injury.

The authors report their experience with the use of a modified method of internal metal plate fixation combined with anterior interbody fusion in six patients with an unstable lower cervical spine. All of the patients had sustained severe cervical spine injuries in accidents. In most of the cases, the operation was carried out at 1 to 4 weeks after injury. The insertion of the metal plate was very simple and maintained the block bone graft in satisfactory position. This alternative method of internal fixation of the cervical spine was not associated with morbidity, allowed very early mobilization, and shortened the hospital stay.

Basilar artery occlusion in multiple trauma: case report.

The authors report a patient who sustained delayed occlusion of the basilar artery (BA) after an automobile accident. This report illustrates the clinical temporal profile of angiographically verified thromboembolic occlusion of the BA. Further propagation of thrombosis and/or late embolization in the proximal BA and distal vertebral artery resulted in fatal brain stem infarction.

Ischemic cerebral edema in primates: effects of acetazolamide, phenytoin, sorbitol, dexamethasone, and methylprednisolone on brain water and electrolytes.

Brain edema was induced in primates (Macaca mulatta) after regional cerebral ischemia produced by selective embolization of the internal carotid artery bifurcation. Details of the alterations in the distribution of water and electrolytes in the brain during the evolution of ischemic cerebral edema have been described elsewhere. The effects of five theoretically useful pharmacological agents were studied. Acetazolamide failed to improve ischemic edema and, rather, increased mortality. Phenytoin definitely prevented both edema and infarction in only the cerebral cortex. Sorbitol was effective to induce dehydration of the affected cortex and the normal brain tissue, with obvious reduction of the brain bulk. High dose steroids showed an ability to modify edema in the cortex, putamen, and white matter. However, animals treated with methylprednisolone rather than dexamethasone showed a better neurological recovery and smaller infarcts.

[Radioisotope ventriculography for functional evaluation of the Ommaya Reservoir (author's transl)].

Thirty nine patients with diagnosis of meningeal leukemia, meningeal lymphoma and leukemia having high risk of meningeal involvement were treated with intraventricular administration of chemotherapeutic drugs via Ommaya reservoir. In all of those patients, radioisotope ventriculography was always performed with ytterbium-169 diethyltriamine pentaacetic acid (169Yb-DTPA) at 1 week after placement of the Ommaya reservoir. In the patients who had normal cerebrospinal (CSF) flow, majority of the radioactivity injected moved to cisterna magna and basal cistern at 4 hours after injection and to subarachnoid space of the cortical surface at 24 hours. Two cases of ventricular catheter occlusion were diagnosed by this method. Two cases of catheter tip misplacement were suspected with computed tomography and confirmed with radioisotope ventriculography. One of the misplacement cases developed focal leukoencephalopathy possibly due to high concentration of methotrexate (MTX) in the brain adjacent to the ventricular cathter. Two cases showed delayed CSF circulation, and the doses of MTX were decreased to be half of the ordinary dose (12 mg/M2 once a week) during initial phase of the treatment. The dose was increased after successful treatment of meningeal dissemination and restoration of the normal CSF flow. Radioisotope ventriculography might be quite useful for detection of the flow of materials placed into Ommaya reservoir. Routine use of this procedure may be helpful to prevent reservoir- and drug-related complications.

Intra-arterial BCNU therapy in the treatment of metastatic brain tumor from lung carcinoma: a preliminary report.

Nine patients with intracerebral metastasis from lung carcinoma were treated with intracarotid and intravertebral artery infusion of 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU). Four of these patients considered definite responders showed unequivocal clinical improvement and definite decreases in the size of tumors evaluated by neurologic examination, computerized tomographic (CT) scan and radionuclide brain scan (RBS). One patient's clinical condition stabilized with doubtful improvement of diagnostic tests (probable responder). The remaining four patients had further unfavorable progression of the clinical and scan findings and were clearly nonresponders. Complications were transient and included: local pain in the eye, orbit, and occipital-nuchal area during infusion in 7 patients, focal seizure in 3 patients, mild confusion with disorientation in 2 patients, and nausea in 2 patients. Our findings suggest that intra-arterial BCNU therapy may be effective and may be used as an adjuvant to surgery and/or radiotherapy for the treatment of metastatic brain tumor from lung carcinoma.

Clinical and radiologic remission in reticulum cell sarcoma of the brain.

Two patients with cerebral reticulum cell sarcoma (CRCS) are reported in whom neurologic abnormalities and radiologic (computerized tomographic [CT] scan) evidence of tumor remitted. In one patient, remission followed craniectomy and corticosteroid therapy and lasted for eight months. In the other patient, at least four remissions occurred over a span of seven years, each in conjunction with the administration of corticosteroids. Corticosteroids may favorably alter the biologic activity of tumor tissue in some cases of CRCS, predisposing to clinical remission and disappearance of tumor on CT scan.

Alterations in cortical oxygen tension during the development of ischemic cerebral edema in primates (Macaca mulatta).

With a closed head primate stroke model, acute cerebral ischemia limited to the middle cerebral artery (MCA) territory was produced by macrosphere embolization of the internal carotid artery bifurcation. Measurements of the oxygen tension (PO2) at the cerebral cortical surface were obtained by continuous on-line mass spectrometry. Percentage of dry weight and tissue sodium, potassium, and chloride concentrations from ischemic and nonischemic hemispheres were determined at various times. With this preparation, we registered the precise onset of cortical surface PO2 depletion, which showed an exponential downward trend (fast component from 0 to 5 minutes, t 1/2 = 0.8 minute, rate of change = 89% per minute; slow component from 5 to 240 minutes, t 1/2 = 285 minutes, rate of change = 0.3% per minute). After the onset of cerebral ischemia, there was an immediate fall of the cortical surface PO2 with reductions of more than 45% at 5 minutes before definite hemiparesis and electroencephalographic abnormalities were recognized. During the secondary phase from 5 to 240 minutes the cortical surface PO2 fell by only an additional 23% of the steady state. Even so, when cortical surface PO2 was maintained at this critically low level, the earliest cerebral cortical edema was evident 180 minutes after MCA occlusion. Thereafter, progressive accumulation of edema fluid in the cortex (90 to 170.8 microliters per g of tissue) and in the white matter (19 to 46.2 microliter per g of tissue) was detected by the end of 240 minutes of cerebral ischemia.

Effects of dexamethasone on tumor-induced brain edema and its distribution in the brain of monkeys.

A human choriocarcinoma was successfully adapted to grow in the brain of monkeys (Macaca mulatta), thus providing a model of tumor-induced brain edema. Four animals were given dexamethasone (3 mg/kg/day) during 3 to 5 days after the onset of clinical signs, and the other five received no treatment for the same period. Tissue water and electrolyte content of treated and untreated animals were compared in cortex and white matter at various distances from the edge of the tumor. In untreated animals, 67.9% and 23.6% swelling was detected in adjacent and remote white matter, respectively, but only 11.8% swelling was noted in adjacent cortex. In animals treated with dexamethasone these percentages of swelling were improved to 32.4% and 11.9% in the corresponding white matter, and to 4.9% in adjacent cortex. The electrolyte changes shown in edematous brain of control animals also demonstrated significant improvement in the dexamethasone-treated group. Tissue radioactivity of 3H-dexamethasone at 60 minutes after intravenous injection was high in the periphery of tumor, adjacent cortex, and white matter, but low in the center of tumor, remote cortex, and white matter. The sites with high concentrations of dexamethasone also showed significant improvement of brain edema after dexamethasone treatment, suggesting that dexamethasone may act directly at these loci.

Experimental regional cerebral ischemia in the middle cerebral artery territory in primates. Part 3: effects on brain water and electrolytes in the late phase of acute MCA stroke.

Experimental regional cerebral ischemia was produced in the middle cerebral artery (MCA) territory in primates (M. mulatta) by macrosphere embolization. Determinations of percentage tissue dry weight and tissue sodium and potassium concentrations were obtained in samples from the ischemic and non-ischemic hemispheres at various time from 12 to 48 hours after the onset of cerebral ischemia. Samples from the cortex normally supplied by the occluded MCA showed maximal accumulation of edema fluid with fluxes in sodium and potassium in reciprocal directions at 12 hours and similar edematous changes in putamen at 24 hours after embolization By 48 hours after MCA occlusion and despite the presence of infarction, partial reversal was observed in the redistribution of water and electrolytes in these gray matter structures. In contrast to cerebral cortex and putamen, the adjacent subcortical white matter showed progressive increases in water content from 12 to 48 hours and definite increases in tissue sodium with decreases in potassium were not observed until 48 hours after MCA occlusion. This late severe white matter edema associated with cerebral infarction appears to be a major factor responsible for the hemispheric swelling observed at this state.